August 2, 2011

Coaching The Coach To Spot Concussions

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When Rich Angarano’s players hit the football field this season, not only will he be watching their tackles, passes and touchdowns, but for signs that a player should be pulled from a game following a hard hit to the head.

Angarano, head football coach of the Bobcats at Brookfield High School, now knows more about traumatic head injuries after taking a course on concussions, required by the student athlete concussion law.

The law says that coaches should not send players back into a game after the player shows symptoms of a concussion or is determined to have suffered a concussion.  The law requires coaches to complete a training course on concussions, review the training materials yearly and complete a refresher course five years after the initial training course.  If a coach doesn’t follow the rules he or she could face civil liability or disciplinary action, such as losing his or her coaching license.

{media_1}Concussions, traumatic brain injuries caused by a blow to the head or body, are common among athletes especially those playing contact sports.  A doctor may see three athletes a week with a concussion during football and hockey seasons. And some hospitals report treating as many as 200-250 athletes a year.

Angarano, who’s been coaching football for the past 25 years, says that the training taught him what concussion signs and symptoms to look for and how to determine when it’s unsafe for an athlete to continue play.  As a player, Angarano admitted that he just shook off a concussion and went back into the game to play, unaware of the danger of the situation.

Fred Balsamo, executive director of the Connecticut Coaching Program at the Connecticut Interscholastic Conference, says the coaches’ training started in May and about 9,200 coaches have been trained so far.

Balsamo compares enforcement of the law to enforcement of the speed limit.  “Are people going to break the law? Yes.  However, it is not a law you want to fool around with.  A coach would be very foolish to disobey the law.”

Spotlight On Concussions

A recent study in Pediatrics highlights the danger of concussions and is trying to raise awareness of what can happen if a young athlete is sent back out before they have recovered from a concussion.  The study found that nationwide 14 percent, or 261, of the 1,827 sudden deaths for young athletes from 1980-2009 occurred because of a concussion.  Of the 261 concussion fatalities, 57 percent, or 148, occurred in football.  Seventeen high school students who died from their head injury were found to have suffered a previous concussion only a few weeks earlier.

The 17 deaths could have been prevented, the study says.  What occurred in these situations is what is known as second impact syndrome.  It occurs when a player suffers a concussion during a game, is sent back in before fully healing and suffers a second concussion.  Second impact syndrome is most common among athletes under the age of 21 and can be fatal.

Connecticut’s law doesn’t prevent concussions, but puts safeguards in place so athletes who have concussion symptoms are taken out of play and won’t suffer a more serious injury such as second impact syndrome.

A lot of the law falls into the coaches’ hands and has them determine when a player should be taken out.  Angarano recalled a good football player he had on his team who had multiple concussions. Not only was he removed from the game following his concussions but also the recommendation was that he reconsiders playing football.

One player that Angarano had last year was taken off the field in a stretcher following a tackle he made.

“We were concerned about his neck.  What we stress is technique; how to play football properly so that you minimize a concussion,” Angarano said. To prevent concussions, Angarano says that he spends a lot of time in the offseason working with players on strengthening their necks.

Bill Labruna, an athletic trainer at the Eastern Rehabilitation Center at Hartford Hospital, says that all the notoriety concussions have been given recently is increasing the number of patients he sees, even those who are only experiencing headaches.  He says there is about a .47 rate of concussions per 1,000 exposures.  Exposures may include any time an athlete is exposed to action whether it is in practice or games. So, for every 2,000 exposures, there would be one concussion.  He says it also varies. One week there may be one concussion and another week there may be three.  As a trainer, he has developed a grading system to diagnose the seriousness of a concussion and the appropriate recovery time.

When Labruna is called into the game, he performs a neurocognitive test.  He checks for balance, memory vision, eye tracking and tracks symptoms.  He also diagnoses the severity of the concussion.  If a player shows symptoms for less than 15 minutes, it is diagnosed as a Grade 1 concussion.  If the player shows symptoms for more than 15 minutes, then it is diagnosed as a Grade 2 and if the player loses consciousness then it is a Grade 3 concussion.

A lot of the difficulty is in diagnosing the actual concussion and determining how long a player should be removed from play, Labruna said.  Unlike a broken leg or other injury, it is not something that can be seen.

“There are lots of schools of thought with grading concussions.  We’d like to be a little more conservative.  With the plan we have, it covers every aspect, and I’d like to think that we’ve covered all the bases,” said Labruna.

New Test And Therapy

There’s a new test in place: ImPACT that has helped in determining when an athlete is fit to return to play.

ImPACT is a 20-minute neuro-cognitive test. Athletes are sometimes given a baseline test at the beginning of the school year when they are healthy.  According to Labruna, it tests memory.

If an athlete suffers a concussion, that person will take the test again and the results will be compared to the baseline test.  If there is no baseline test taken, then the athlete’s results will be compared to the national average.  The athlete will continue to be tested until he or she shows no symptoms from the concussion and then will be put through an exertion test to determine if play should be resumed.

Adam E. Perrin, a doctor at Middlesex Hospital and member of the CT Concussion Task Force, said that before he gives an ImPACT test, the patient would have already gone to the emergency room and had an imaging test.  For the test, the athlete will be placed in a quiet room.  There are 22 different symptoms that it tests for and there is a range from 0-6 for the severity of the symptoms.  If there is a score of 0, this means that the symptoms are absent.  If there is a score of 6, this means that the symptoms are most severe.  Based on the results, Perrin will determine when a player can return to the sport.

Perrin usually says to take the athlete out of his sport and gym or any other physical activity until concussion symptoms go away.  It is more difficult to determine if he should be taken out of school.  He may make certain suggestions like allowing the student to wear sunglasses to school or to take them out of cognitive classes like math.  Perrin says that his most busy season as far as seeing concussion patients is during the football season. He sees about 12-15 concussion patients a month and 200-250 a year.

Chip Dorwin, who recently retired as athletic director at Guilford High School, the first public high school in the state to use ImPACT testing, said that during the baseline test, they don’t necessarily try to confuse the athlete but they try to distract him while taking the test to further test brain function.  At this particular high school, the athlete is tested again in his junior year if he plays contact sports such as football, hockey and soccer. The test is more widely used in Connecticut.  At Harford Hospital, for instance, there are eight schools in the program and seven of the schools used the testing.

A new treatment that was developed in Connecticut by Dr. Michael Lee is cocoon therapy.  This is usually reserved for the patients with the most severe concussion symptoms.  According to Perrin, for a period of three-to-five days a patient will be confined to a cool, dark, quiet room and will only be able to get up to eat or use the bathroom.  During this time, the patient would not be allowed to use any sort of technology which means no television, no computer and especially no texting because this is a big trigger for concussion symptoms.  It is reserved for the most severe because it is a hard therapy to complete.

Gayla Cawley is an intern from the University of Connecticut.

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